Information Collection

Certificates for Health Care Benefits

IC 12211 under ICR 200207-1115-001 · OMB 1115-0226.

Documents and Forms

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Information Collection (IC) Details

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IC Title:	Certificates for Health Care Benefits	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 21,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	21,000	0	7,000	14,000
Annual IC Time Burden (Hours)	37,240	0	11,620	25,620
Annual IC Cost Burden (Dollars)	4,550,000	2,450,000	0	2,100,000

Documents for IC

Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.